Specialist assessment and treatment from Mr Ashley Simpson, Consultant Peripheral Nerve Surgeon. Clear diagnosis, evidence-based treatment and carefully planned carpal tunnel release for straightforward, severe, atypical and recurrent cases.
Private consultations in Central London and Stanmore. Self-pay and insured patients welcome.
What Is Carpal Tunnel Syndrome?
The Basics
Carpal tunnel syndrome occurs when the median nerve is compressed as it passes through a confined space at the wrist. The roof of this space is formed by the transverse carpal ligament; the floor and sides are formed by the wrist bones.
The median nerve supplies sensation to the thumb, index finger, middle finger and part of the ring finger. It also powers important muscles at the base of the thumb. Pressure on the nerve can therefore cause tingling, numbness, pain, loss of dexterity and, in more advanced cases, weakness or wasting of the thumb muscles.
Symptoms often begin intermittently, particularly at night. If compression becomes severe or prolonged, numbness may become constant and nerve recovery after treatment may be incomplete. Timely assessment matters when there is weakness, muscle wasting or persistent loss of sensation.
Why Symptoms Are Often Worse at Night
Many patients wake with a numb or painful hand and obtain temporary relief by shaking it. Wrist flexion during sleep and changes in tissue pressure can further reduce the available space within the tunnel.
Night symptoms are characteristic, but they are not diagnostic on their own. Not every numb or painful hand is caused by carpal tunnel syndrome.
Symptoms and Signs to Recognise
Typical Symptoms
- Pins and needles or numbness affecting the thumb, index finger, middle finger and part of the ring finger
- Symptoms that wake you at night or are worse on waking
- Temporary relief from shaking or rubbing the hand
- Pain in the palm or wrist that may extend into the forearm
- Difficulty with buttons, handwriting, phone use or other fine tasks
- Dropping objects or feeling that the hand is clumsy
- Weakness of thumb pinch or opposition
The little finger is usually spared. Symptoms confined to the little finger, arising from the neck, or involving the whole limb may suggest a different or additional diagnosis.
Warning Signs
- Constant rather than intermittent numbness
- New or progressive thumb weakness
- Visible flattening or wasting of the muscles at the base of the thumb
- Increasing clumsiness or frequent dropping of objects
- Rapidly worsening symptoms
- Symptoms following a wrist fracture, dislocation or other trauma
- Severe pain, weakness or new sensory loss after previous carpal tunnel surgery
Diagnosis: Not Every Numb Hand Is Carpal Tunnel Syndrome
The first gold standard is the correct diagnosis. A specialist consultation should establish whether the median nerve is compressed at the wrist, how advanced the compression is, and whether another condition is contributing to the symptoms.
Clinical Assessment
Mr Simpson takes a detailed history and examines the full nerve pathway. Assessment includes the distribution of altered sensation, thumb muscle bulk and power, hand dexterity, provocative signs at the wrist and evidence of compression elsewhere in the arm or neck.
Nerve Conduction Studies and EMG
Electrical tests are not required in every clear, typical case. They are particularly useful when symptoms are atypical, severe, recurrent, associated with weakness, or when diabetes, polyneuropathy, cervical radiculopathy or another nerve disorder may be present. They can also provide an objective baseline before complex or revision treatment.
Ultrasound and Imaging
Ultrasound can assess the median nerve, reveal anatomical variation and identify a cyst, tumour or other structural cause in selected cases. MRI is not routinely needed for ordinary carpal tunnel syndrome but may be appropriate where the presentation is unusual or another diagnosis is suspected.
Important Alternative or Additional Diagnoses
- Cervical radiculopathy from the neck
- Median nerve compression in the forearm, including pronator syndrome
- Cubital tunnel syndrome or another upper-limb entrapment neuropathy
- Generalised peripheral neuropathy, including diabetic neuropathy
- Thumb-base arthritis, tendon disorders or other causes of hand pain
- Double-site nerve compression
Operating on the wrist cannot help symptoms that are being generated elsewhere. The diagnosis must fit before surgery is offered.
Why Choose a Consultant Peripheral Nerve Surgeon?
Carpal tunnel release is one of the most frequently performed hand operations. Many appropriately trained hand, orthopaedic and plastic surgeons perform it safely, and a routine pathway may be entirely suitable for a clear, uncomplicated case.
However, carpal tunnel syndrome is fundamentally a disorder of the median nerve. Choosing a surgeon whose consultant practice is centred on peripheral nerve diagnosis, decompression, repair and reconstruction provides an especially comprehensive pathway. In Mr Simpson's view, this is the gold-standard specialist approach to a median nerve operation, particularly when the diagnosis, nerve function, anatomy or previous treatment is not routine.
The Specialist-Led Treatment Pathway
Confirm the Diagnosis
Establish that the symptoms genuinely arise from median nerve compression at the wrist and identify any coexisting nerve problem.
Grade Severity and Urgency
Intermittent night symptoms, constant numbness, weakness and thenar wasting do not carry the same prognosis or require the same timing.
Choose Proportionate Treatment
Use non-operative treatment where it is reasonable, without delaying decompression when there is evidence of advanced nerve damage.
Perform a Complete, Carefully Planned Release
Select an evidence-based technique appropriate to the anatomy, previous surgery and individual patient's needs.
Review Recovery
Monitor wound healing, scar comfort and neurological recovery, and investigate promptly if the expected improvement does not occur.
Treatment Without Surgery
Not every patient needs an operation. Treatment should reflect symptom severity, duration, functional impact, examination findings, test results and personal preference.
Night Splint
A neutral-position wrist splint worn at night is often the first treatment for mild or intermittent symptoms. A trial of approximately four to six weeks is reasonable if there is no progressive weakness or advanced nerve damage.
Activity and Health Factors
Reducing prolonged wrist flexion, forceful gripping or exposure to vibrating tools may help. Diabetes, thyroid disease, inflammatory arthritis and fluid retention should be managed appropriately. Pregnancy-related symptoms often improve after delivery, although severe neurological deficit still requires specialist review.
Corticosteroid Injection
An injection can reduce symptoms in the short term and can sometimes support the diagnosis. It is not reliably curative, and symptoms often return. Repeated injections should not become a substitute for definitive assessment when nerve compression is progressing.
When Not to Delay
A prolonged non-operative trial may be inappropriate when numbness is constant, thumb weakness or wasting is present, nerve tests show advanced damage, or symptoms are rapidly worsening.
When Is Surgery Recommended?
Carpal tunnel release may be appropriate when:
- Symptoms remain troublesome despite an appropriate trial of night splinting or other non-operative care
- Sleep, work, driving, dexterity or quality of life is significantly affected
- Symptoms recur after a corticosteroid injection
- Numbness has become constant
- Thumb weakness or thenar muscle wasting is developing
- Nerve conduction studies show significant median nerve damage
- The patient prefers a definitive treatment after informed discussion
- Acute compression follows trauma and requires urgent decompression
The decision is individual. In mild disease, non-operative care may be entirely reasonable. In severe disease, the purpose of surgery may be to prevent further deterioration as well as to improve symptoms.
Carpal Tunnel Release: What the Operation Involves
Where surgery is recommended, Mr Simpson performs a consultant-led carpal tunnel release, commonly as a day-case procedure under local anaesthetic.
Through a carefully positioned limited incision, the transverse carpal ligament is completely divided under direct vision to create more space for the median nerve. The nerve and its motor branch are protected and unnecessary manipulation of the nerve is avoided. The wound is then closed and covered with a small dressing.
The procedure usually takes approximately 20 minutes in a straightforward primary case. Revision, post-traumatic or anatomically complex operations take longer and require a different plan.
Mini-Open or Endoscopic Release?
Both mini-open and endoscopic release are accepted techniques. High-quality evidence shows no important difference in long-term patient-reported outcomes. Endoscopic surgery may allow an earlier return to work for some patients but is not automatically safer or more effective.
The priority is not marketing the smallest incision. It is achieving a complete release while protecting the median nerve, using a technique in which the surgeon is appropriately trained and experienced.
1. Correct Level
Confirm that compression is at the carpal tunnel and plan for any anatomical or previous surgical variation.
2. Complete Release
Divide the full constricting ligament so that residual compression is not left behind.
3. Nerve Protection
Protect the median nerve and its motor and sensory branches throughout the procedure.
Expected Outcomes and Surgical Risks
Most appropriately selected patients improve after carpal tunnel release. Night pain and tingling may settle quickly. Constant numbness, weakness and muscle wasting usually recover more slowly and may remain incomplete where nerve damage was already advanced.
In 100 patients
Reported feeling better after surgery at one year in the NHS England decision aid
Operating time
Typical operating time for a straightforward primary release
Admission type
Most patients return home on the day of surgery
Risks to Discuss
- Pain, bruising, swelling and temporary reduction in grip strength
- Scar tenderness or "pillar pain" at the heel of the hand
- Infection, bleeding, stiffness or delayed wound healing
- Persistent numbness where the nerve was already severely damaged
- Incomplete relief if the original diagnosis was wrong or another compression coexists
- Incomplete release or recurrent compression
- Injury to the median nerve or one of its branches, which is uncommon but potentially serious
- Complex regional pain syndrome, which is rare
- Need for further investigation or revision surgery
The NHS England decision aid estimates infection after release at approximately 3 to 7 per 1,000 operations and long-term nerve damage causing permanent pain or numbness at approximately 1 per 1,000. Individual risk varies and will be discussed during consent.
Recovery After Surgery
First 48 Hours
Keep the hand elevated when resting, move the fingers regularly and use the hand for light activities as advised. Keep the dressing clean and dry. Simple analgesia is usually sufficient for most patients.
10 to 14 Days
The wound is reviewed and sutures are removed if required. Gentle scar care begins once the wound is fully healed. Many patients can perform desk-based duties within one to two weeks, depending on comfort and the hand treated.
Two to Four Weeks
Light manual tasks are gradually reintroduced. Driving can resume only when the wound is comfortable, grip and control are adequate, an emergency manoeuvre can be performed safely, sedating medication is no longer required and insurance requirements are satisfied.
Four to Eight Weeks and Beyond
Heavier manual work and forceful gripping may require four to eight weeks. Scar sensitivity and pillar discomfort can take longer to settle. Sensory and motor recovery in severe carpal tunnel syndrome may continue for many months.
Routine postoperative splinting or supervised hand therapy is not required after an uncomplicated release. Therapy is arranged selectively for stiffness, swelling, scar sensitivity, weakness, complex regional pain or demanding return-to-work requirements.
Complex, Recurrent and Previously Operated Carpal Tunnel Syndrome
This is where peripheral nerve subspecialist expertise becomes particularly important.
Specialist Assessment Is Advised For:
- Symptoms that never improved after the first release
- Symptoms that improved and later returned
- New pain, numbness or weakness arising immediately after surgery
- Suspected injury to the median nerve or palmar cutaneous branch
- Severe thenar wasting or longstanding constant numbness
- Carpal tunnel syndrome following wrist trauma or fracture
- Atypical symptoms suggesting proximal median nerve compression or double-site compression
- Diabetes, polyneuropathy or another condition that makes test interpretation more complex
- Suspected mass, cyst, anomalous muscle or other structural cause
Revision surgery is not simply a repeat of the first operation. It may require review of the original diagnosis, detailed neurophysiology or ultrasound, external neurolysis, management of scar tethering, treatment of nerve injury, coverage of the nerve, or reconstruction in selected cases. The plan must be tailored to the cause of failure.
Frequently Asked Questions
Do I need nerve conduction studies before surgery?
Not always. A clear and typical presentation can often be diagnosed clinically. Tests are particularly helpful if symptoms are atypical, severe, recurrent, associated with weakness, or complicated by another possible nerve disorder.
Is carpal tunnel surgery painful?
Local anaesthetic numbs the operative area. Soreness, bruising and scar sensitivity are expected afterwards, but most patients manage with simple pain relief. Individual experience varies.
How quickly will the numbness improve?
Intermittent tingling and night waking may improve quickly. Constant numbness and weakness can take months and may not recover completely if the nerve was already severely damaged.
Is endoscopic or "keyhole" surgery better?
Neither technique has demonstrated superior long-term patient-reported outcomes. The safest choice is an evidence-based technique performed by a surgeon who is appropriately trained and able to achieve a complete release while protecting the nerve.
Can carpal tunnel syndrome return?
Yes, although true recurrence is uncommon. Persistent or recurrent symptoms may reflect incomplete release, scar tissue, another site of compression, an alternative diagnosis or progression of an underlying neuropathy. Specialist reassessment is recommended before further surgery.
What if my first carpal tunnel operation did not work?
Do not assume that another simple release is the answer. Mr Simpson will review the original symptom pattern, operation details, examination and investigations to identify why improvement did not occur and whether revision nerve surgery is likely to help.
Can both hands be treated?
Both hands can be assessed together. Whether operations are staged or performed at the same sitting depends on severity, personal circumstances, help available at home and the functional demands placed on each hand.
How soon can I return to work?
As a broad guide, desk-based work may be possible in one to two weeks, light manual work in two to four weeks and heavy manual work in four to eight weeks. Recovery should be tailored to your occupation, hand dominance, wound and symptoms.
Specialist Carpal Tunnel Care in London
"Carpal tunnel release is common, but the median nerve is not routine. My aim is to make the right diagnosis, operate at the right time and protect every functioning part of the nerve."
— Mr Ashley Simpson, Consultant Peripheral Nerve Surgeon
Mr Simpson welcomes self-referring patients and referrals from GPs, neurologists, rheumatologists, orthopaedic and plastic surgeons, physiotherapists, hand therapists and other healthcare professionals.
Clinical Sources
Clinical information on this page has been reviewed against the following sources:
This page provides general information and does not replace an individual medical consultation. Treatment recommendations depend on the patient's symptoms, examination, investigations and personal circumstances.
Carpal Tunnel Syndrome: Expert Diagnosis and Surgery in London